Wanted: fecal matter from healthy adults with a regular constitution and a good heart. Screening is rigorous. Reimbursement is modest but can add up for those willing to make daily donations of waste that would otherwise be flushed away
Fecal transplants are being used increasingly to treat Clostridium difficile, an often intractable and debilitating bacterial infection. The potential for expanding the therapeutic applications of fecal transplants sent Canadian researchers on a quest to pinpoint what precisely motivates stool donors and how they might recruit more volunteers.
For their study, 802 people in the United States, Canada and England completed an online survey that assessed their attitudes about becoming stool donors. Respondents were, not surprisingly, put off by the unpleasantness that would be involved in collecting stool samples. And most said the time commitment that would be required would be a deterrent — most centers require “deposits” at least three times a week.
But nearly half said the desire to help others was a powerful incentive. And one-third said the modest financial compensation — about 20 to 30 Canadian dollars per sample, or about $15.50 to $23 in American dollars — would add to their willingness to help.
Over all, more than half of the participants who took the time to respond to the 32 survey questions scored high on their willingness to become stool donors.
The researchers, from the University of Alberta in Edmonton, Canada, presented their work in Washington on Tuesday at Digestive Disease Week, one of the largest international gatherings of physicians and researchers in the fields of gastroenterology, endoscopy, gastrointestinal surgery and liver disease.
“Just telling people how much it helps patients when they receive the transplants could make them even more motivated,” said Breanna McSweeney, a medical student at the University of Alberta, who was the study’s lead author.
The Food and Drug Administration has approved fecal transplants only as a last resort for treating C. difficile infections after antibiotics have failed. But a study published Saturday in The New England Journal of Medicine found that fecal transplants were as effective as antibiotics as a first line of treatment for the infections, which kill some 14,000 people in the United States each year.
Researchers are also exploring the use of fecal transplants for other bowel diseases like ulcerative colitis and a range of other conditions.
Though stool banks in the United States said they have a sufficient supply of stool samples to meet the current demand, Canadian researchers said they have fecal transplant programs in only a few cities and anticipate the need to expand stool banks in order to provide services to patients in more remote areas and other parts of the country.
“We are always actively looking for more and more donors,” said Dr. Karen Wong, a co-author on the study. The stool bank at the University of Alberta often runs low, she said, and “sometimes I have to call the donor when we want to do a procedure and ask them to make a donation the day before, so we have the stool ready.”
Becoming a stool donor isn’t easy. Volunteers who apply to be stool donors at OpenBiome, a nonprofit stool bank based in Boston, go through an intensive screening process. First, they fill out an online health questionnaire. Then, based on the answers, they may or may not be invited in for an hourlong clinical interview, which includes questions about their current health status, their health history and their family’s health history. If they pass the interview, their blood and stool undergo extensive testing to screen for pathogens and infectious diseases.
The vast majority of applicants are rejected, said Carolyn Edelstein, OpenBiome’s executive director. “Only about 3 percent make it through our screening process,” she said. “We like to joke with our donors that it’s easier to get into Harvard or M.I.T. than be a stool donor.”
Anyone with allergies or asthma, a family history of colon cancer, autoimmune diseases or infectious diseases, or a high body mass index is usually disqualified, Ms. Edelstein said. “If you traveled to certain regions of the world or recently got a tattoo or recently changed sexual partners, that might exclude you or put you on hold for a few months,” she said. “We count on people to be honest.”
Gabriel Taylor, 22, who just graduated from Tufts University, was one of those rejected. Though he was invited in for an interview in 2016 after filling out the online questionnaire, he received notification a few days later that he didn’t qualify.
“They never told me why, just that they didn’t want me,” he said. He was disappointed because “it was a lot of money — enough to cover rent for a college student. And for something I already do.”
Once accepted by OpenBiome, donors must make a commitment to provide at least three samples a week for a period of at least two months. And they must come in to a clinical center to pass the sample, which earns them $40 for each stool that is up to snuff, Ms. Edelstein said.
“We encourage them to come every day,” she said. “Some donate multiple times a day — it depends how productive they are.”
At other centers, including the University of Alberta, volunteers can collect the sample at home and drop it off.
An average-size stool can provide treatment for five individual patients, Ms. Edelstein said. A single dose is usually sufficient to treat a C. difficile infection.
Ed, a 32-year-old father of two who lives in the Boston area and works in digital marketing, has been donating stool for two years. (Ms. Edelstein asked that his last name not be disclosed because some donors have been harassed by patients who believe fecal transplants can cure various medical conditions but who are unable to get access to a clinical trial.)
Ed said he first applied when his wife mentioned donating stool “half jokingly” after seeing a post on social media. But once he was accepted into the program, he became a regular donor, making a stop by the clinical center each morning on his way to work to deliver a stool sample as part of his daily routine.
The satisfaction he gets from knowing he’s had a beneficial impact on someone’s health makes it worthwhile, he said.
“To do something as simple as going in and making a stool donation, and know that it can literally change someone’s life from one day to the next when they have a disease like C. diff, where they can’t even leave their house and the next day they can go about things fairly normally — to see that impact makes me feel good,” he said.